Client-Provider Relationships in a Community Health Clinic for People Experiencing Homelessness: A Critical Ethnography

People who are experiencing homelessness have the highest rates of morbidity, and the lowest age of mortality in the Canadian population. The importance of health care relationships in addressing the needs of people who are experiencing homelessness has been demonstrated. However, two gaps still exist in the literature. Firstly, the dialectical relationship between space/place and social relations has largely been neglected in the context of health care and homelessness. Secondly, there is a dearth of research on the role of both formal and informal policies on the enactment of client-provider relationships in this context. Therefore, in this study threeo research questions are addressed: 1) How is ‘place’ experienced by clients and providers within a community health clinic for people who are experiencing homelessness; 2) How are client-provider relationships enacted within this contexts? and, 3) How do clinic-level and broader social and health policies shape relationships in this context? These questions are explored within a critical theoretical perspective, and utilizing a critical ethnographic methodology. Data were collected using multiple methods of document review, participant observation, in-depth interviews and focus groups. The participants included clients at a community health clinic, and all clinic service providers. Findings from this study focus on the power relations between clients and providers as they negotiate both formal and informal policies to meet both convergent and divergent needs to promote health. Similarly, clients and providers contested the space of the clinic to form their meanings of the place. This study has implications for individual health care practices, for developing health promoting places, for informing local policies, and for advocating for the refinement of system policies. Health care providers must ensure that they are attuned to the structural factors that will enhance or limit their ability to practice in a way that they consider optimal. As well, opportunities for clients to assume leadership positions need to be considered so that clinics will be responsive to client needs. In terms of system policies, health care providers need to continue to give time to social and political advocacy in order to refine systems to better serve clients. In conclusion, promoting health with people who are experiencing homelessness will take refinement both in personal practice and in local/systemic policies.

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